Every finding on record at Compassionate Care Hospice of Kansas City, LLC

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with State emergency management agencies. Corrected on site.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #13: Medication profile dated 12/30/2023 included Gavalax 17Gm 2x per day per instructions po. No evidence of instructions for use.

Upon patient record review, 4 of 14 (Patient #1, #11,#13,#14:) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Identified on SN SOC assessment with seizures. No evidence on the POC of problem/goals/interventions of neuro/seizures. Corrected on site. Patient #11: Identified on SN SOC assessment patient has trilogy ventilator. On psychosocial eval noted needs help with DNR and funeral planning. No evidence on POC for problem/goals/interventions for Ventilator use, DPOA and Funeral planning. Patient #13: SN SOC assessment identified Braden score 14- moderate risk for pressure ulcer, and fall risk score of 18>10- high risk of falls. No evidence on POC for problem/goals/interventions for skin/integrity at risk for pressure ulcer and safety/fall risk. Patient #14: Patient on O2 therapy, no evidence on POC for problem/goals/interventions for use of oxygen.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #13: Order dated 12/30/2023 included Gavalax 17Gm 2x per day per instructions po. No evidence of instructions for use.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient # 1: Nurse touched patient trying to awaken patient and got into clean area of bag without using hand sanitizer. Patient #2: Nurse touched patient, adjusting oxygen nasal prongs on face prior to use of sanitizer. After sanitizing and starting patient care, got back into clean bag with out cleansing hand prior.

Upon patient record review, 7 of 14 (Patient #2,#3,#5,#7, #8,#12,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: Patient identified on SN SOC as high fall risk. No evidence on the Aide POC/Assignment sheet of at risk for falls. Corrected on site. Patient #3: Comprehensive POC identifies patient at risk for falls. No evidence on the Aide POC/Assignment sheet of at risk for falls. Corrected on site. Patient #5: Patient identified on SN SOC as fall risk. No evidence on the Aide POC/Assignment sheet of at risk for falls. Corrected on site. Patient #7: Comprehensive POC identifies patient at risk for falls. No evidence on the Aide POC/Assignment sheet of at risk for falls. Corrected on site. Patient #8: Comprehensive POC identifies patient at risk for falls. No evidence on the Aide POC/Assignment sheet of at risk for falls. Corrected on site. Patient #12: Patient receiving O2 therapy as of 2/8/2024. No evidence on aide POC/assignment of O2 precautions. Patient #14: Patient receiving O2 therapy, no evidence on aide POC/assignment of O2 precautions.

Upon patient record review 1 of 14 (Patient #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #11: Order 6/21/2024 included HHA visits 1x week. No evidence of a visit or missed visit for weeks of 6/30, 7/1, and 7/14/2024.

Upon patient record review 1 of 14 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8: First Aide visit occurred 7/9/2024. No evidence of supervisory visits until 7/31/2024 (22 days).

Upon observation, there was no evidence volunteers are used in day to day direct patient care roles.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Per annual evaluation for 2023, year end obtained 3.94 % of total care hours.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Advance Directives Patient #4: Record documented DNR status, no evidence of DNR paperwork in record. Corrected on site (staff went to patient home and obtained).

Upon patient record review, 3 of 14 (Patient #1,#2,#10) did not have evidence that the hospice provided the following information: • Hospice election form. Patients #1,#2,#10: No evidence in Facility clinical records of an Election of benefit. Corrected on site.

Based on policy review, clinical record review, home visit observation and interview the agency failed to: - Perform a comprehensive assessment that considered complications and risk factors that affect care planning(L526); and - Conduct a comprehensive assessment that considered complications and risk factors that affect care planning included an effective drug regimen review (L530). The cumulative effect of these deficient practices has the potential for unmet patient needs and adverse medication events.

Based on policy review, record review and interview, the agency failed to ensure that the comprehensive assessment considered complications and risk factors that affect care planning in, but not limited to, two (Patients/Records #1 and #3) of five full records reviewed. The deficient practice has the potential to affect all patients on service with the hospice agency. Findings included: Review of the agency's policy titled, "Assessments," dated 11/29/2019 showed that the comprehensive assessment will include complications and risk factors that affect care planning. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/29/2022 with a terminal diagnosis of traumatic brain injury, and secondary diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), nausea, and frequent falls. The patient resided in his/her own home with his/her spouse providing care. Review of the comprehensive assessment dated 06/29/2022 showed that: - The patient had dysphagia leading to recurrent aspiration, however the respiratory assessment showed that there were no abnormal respiratory findings identified, and appetite problems that did not significantly affect the patient; - The patient had no falls in the past three months; - The patient ambulated with the use of a wheelchair; - The patient used oxygen; - The nurse communicated with the facility staff regarding the patient's plan of care; and - The nurse provided wound care and documented the care in the wound addendum. During an interview on 07/27/2022 at 11:30 AM, the area clinical vice president stated that the comprehensive assessment was inaccurate. The patient did have: - Issues with dysphagia, frequent coughing during meals; - The patient had a history of frequent falls; - The patient ambulated with the use of a walker/cane; and - The patient did not use oxygen, was not in a facility, and did not have a wound. PATIENT/RECORD #3: Review of the rehabilitation and healthcare center progress note, dated 05/13/2022, showed in part: - Squamous (scales) cell carcinoma of the scalp; - Continue with topical management of wound; and - Consult hospice to evaluate and treat. Patient resided in a long term care facility (LTCF). Past history: Active medical problems included pressure ulcer on buttock. Review of the LTCF order summary report dated 05/16/2022, showed: - Cleanse wound at the top of head with normal saline, apply triple antibiotic ointment, and leave open to air; and - Apply mediseptic (skin protective cream) three times a day for wound on buttock. Review of the comprehensive assessment dated 05/17/2022 showed: - Abnormal findings of the hair/scalp/skull melanoma (cancerous tumor from pigmented cell in the skin) of the scalp; - The documentation failed to include an assessment of the melanoma of the scalp; and - The documentation failed to include an assessment of the buttock. Review of the hospice registered nurse (RN A) visit note documentation dated 07/26/2022 beginning at noon, showed integumentary (skin) assessment findings: Pale and poor turgor. During an interview on 07/26/2022 at 12:37 PM, the patient stated that his/her bottom was sore depending on how long and where he/she sits. He/she spends so much time on his/her bottom, thinks it (buttock) is red now, and because of the "bed sore" sitting on a bedpan hurts so the LTCF staff let him/her go the the bathroom in the chair. Observation on 07/26/2022 at 1:10 PM, during the patient's home visit, showed RN A failed to assess the patient's buttocks. During an interview on 07/26/2022 at 1:20 PM, RN A stated that: - The hospice aide (HHA) sent him/her a picture of the patient's buttocks this morning (07/26/2022); - RN A told the HHA to ask the LTCF to have the wound nurse look at the wound; and - RN A also stated that last week, he/she had asked the LTC facility nurse for measurements and he/she didn't have any. Record review failed to show an assessment of the buttocks by RN A. During an interview on 07/27/2022 at 12:00 PM, RN A stated that he/she assessed the patient's buttocks today. The patient has a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough [dead skin] ) on the left buttocks, further up on the hip and measured 0.2 centimeters (cm) by 0.2 cm. The findings were reviewed with the area clinical vice president and administrator on 07 /27/19 at 2:55 PM. No additional information was provided by the survey exit.

Based on policy review, agency and facility record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile/plan of care (POC) in, but not limited to, two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication-Management," dated 10/28/2021, showed in part: - Medication profile will be established by the registered nurse (RN) upon admission to the hospice program, the medication plan of care will include all prescription and over the counter medications; - A current medication profile will remain in the patient's home folder and will be updated as modifications are made; and - Medication reconciliation will be done at admission, recertification, a change in patient's condition requiring medication changes, and when a medication is discontinued. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/18/2022 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a long term care facility (LTCF). Review of the document titled, "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report," dated 07/12/2022 showed that the patient had orders for: - Lorazepam 0.25 to 1 milliliter (ml) under the tongue every four hours as needed for restlessness or anxiety; - Morphine concentrate 0.25 to 1 ml under the tongue hourly as needed for pain, shortness of air, or comfort; and - Zofran 4 milligram tablet every six hours as needed for nausea. The LTCF medication administration record printed 07/26/2022 failed to contain orders for lorazepam, morphine, or Zofran. RECORD/PATIENT # 3: Observation on 07/26/2022 beginning at 1:10 PM, during the patient's home visit at the LTCF, showed the following discrepancies with the hospice medication profile: - The LTCF medication administration record (MAR) showed the patient was taking Novolog insulin aspart (fast acting insulin) 15 units three times a day. The agency medication profile showed Novolog insulin aspart 13 units three times a day; - The LTCF MAR showed Oxycodone (used to treat moderate to severe pain) 5 milligrams (mg) one tablet for moderate pain and two tablets for severe pain. The agency medication profile showed Oxycodone 5 mg one tablet and two tablets, and did not include the instructions to take one tablet for moderate pain and two tablets for severe pain; and - The agency medication profile showed docusate sodium (laxative) 100 mg two tablets at bedtime for stool softener. The LTCF MAR did not include docusate sodium. The findings were reviewed with the area clinical vice president and administrator, on 07 /27/19 at 2:55 PM. No additional information was provided by the survey exit.

Based on policy review, record review, and interview, the agency failed to: - Develop an individualized plan of care based on problems identified in the initial, comprehensive and updated comprehensive assessments, that included all services necessary for the management of the terminal illness (L545); - Develop an individualized plan of care with frequency of services necessary to meet the specific patient and family needs (L547); - Provide drugs and treatments necessary to meet the needs of the patient (L549); and - Provide medical supplies and appliances necessary to meet the needs of the patient (L550). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care (POC) in five (Records/Patients #1, #2, #3, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Hospice Plan of Care," dated 11/30/2021, showed in part: - The hospice must develop an individualized written plan of care for each patient; - The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; - When the patient resides in a nursing facility the hospice plan of care (POC) is established and maintained in consultation with the facility staff; and - All care provided must be in accordance with the hospice POC. Review of the agency's policy titled, "The Provision of Wound and Skin Care," dated 01/20/2022, showed in part, assessment of the integumentary system is part of the comprehensive total body assessment, a separate order is not required to perform an assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/29/2022 with a terminal diagnosis of traumatic cerebral edema (swelling of the brain), and secondary diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), and nausea. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 07/26/2022 showed that the report failed to contain any specific goals or interventions for patient care including, but not limited to management of dysphagia, nausea, aphasia, and falls. During an interview on 07/27/2022 at 11:30 AM, the area clinical vice president stated that the Care Plan report showed the interventions and goals for the patient, and the Care Plan report is not reviewed during the interdisciplinary team meeting. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/18/2022 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a long term care facility (LTCF). Review of the documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 06/14/2022, 06/28/2022, 07/12/2022, and 07/26/2022 showed the report failed to contain any specific interventions and goals for patient care. During an interview on 07/27/2022 at 02:50 PM, the area clinical vice president stated that the Care Plan report shows the interventions and goals for the patient, and the Care Plan report is not reviewed during the interdisciplinary team meeting. RECORD/PATIENT #3: Review of the comprehensive assessment completed 05/17/2022 showed: - Admitted to hospice on 05/17/2022; - Reason for admission Parkinson's disease (chronic disorder of the nervous system, characterized by tremors [shaking]); - Primary hospice diagnosis neurological disorders including ALS (amyotrophic lateral sclerosis- nervous system disease that affects the brain and spinal cord); - Abnormal neurological findings with seizures occasionally; - Moderate pain rated a five (a scale used to rate pain using a scale zero to ten, zero representing no pain and ten the worst pain), and the patient's pain goal was zero; - The pain location was his/her head and described as intermittent and less than daily and medication relieves pain; - Oxycodone (used to treat moderate to severe pain) 5 milligrams (mg), one tablet or two tablets every four hours as needed for pain; - Abnormal findings of the hair/scalp/skull melanoma (cancer lesion) of the scalp (no further assessment); - Appetite problems that significantly affect the patient; - A bowel regimen initiated or continued; and - The patient was a diabetic and taking insulin and blood sugars checked four times a day. The plan of care failed to show individualized problems, goals, and interventions for seizures, pain, melanoma of the scalp, chest pain/angina, nutrition, bowel regimen, diabetes diagnosis and diabetes management. Review of the LTCF plan of care, revised 06/07/2022, showed in part, the following: - Pain scale: Record every shift zero to one (no pain), two to three (mild pain), four to five (moderate pain), six to seven (severe pain), eight to nine (very severe pain), and ten (worst possible pain); - Oxycodone 5 mg, one tablet every four hours as needed for moderate pain; - Oxycodone 5 mg, two tablets every four hours as needed for severe pain; - Skin integrity: * Moisture associated maceration (softening by soaking in liquid) to his/her buttock; * Carcinoma to head; * Currently has a stage three pressure wound (full thickness tissue loss) to his/her coccyx (buttocks); * Cleanse cancer lesion on top of head with normal saline, apply triple antibiotic ointment and leave open to air daily; * Cleanse perineal area and apply Medseptic (skin protectant cream) three times a day for wound treatment; * Low loss air mattress; - The patient has diabetes mellitus (a group of diseases that result in too much sugar in the blood); - Monitor blood sugar before meals and hour of sleep; and - The hospice plan of care failed to show the above information. Review of the interdisciplinary group comprehensive assessment and plan of care update report dated 6/14/2022 and 06/28/2022, showed the RN documented the patient's coccyx "is close to breaking down" (no further assessment). The documentation failed to show the hospice plan of care was updated. Review of the RN visit note dated 06/29/2022, showed the patient had areas on top of the head that were blistery (no further assessment). The documentation failed to showed the hospice plan of care was updated. Review of the interdisciplinary group (IDG) comprehensive assessment and plan or care report dated 07/12/2022, the RN details showed the patient's coccyx is "close to breaking down" and barrier cream is being used. The documentation failed to show the hospice plan of care was updated and there was no interim order for barrier cream. Review of the master in social work (MSW) visit note report dated 07/21/2022, showed the patient's pain level was eight, the patient would like pain medications, the patient feels Tylenol only brings pain down to a seven on a scale from one to ten. The case manager was notified. The documentation failed to show the hospice plan of care was updated. Review of the IDG comprehensive assessment and plan or care report dated 07/26/2022, the RN details showed the patient's coccyx is "close to breaking down" (no assessment). The clinical manager details showed the patient has excoriation (break down) on his/her buttocks and stays mostly in bed. The social worker details showed the patient's pain level was eight, the patient would like pain medications, the patient feels Tylenol only brings pain down to a seven on a scale from one to ten. The physician suggests the facility physical therapy assess the patient for pressure relief and offloading. During an interview on 07/26/2022 at 12:37 PM, during the patient's home visit, the patient stated that his/her bottom is sore depending on how long and where he/she sits. He/she spends so much time on his/her bottom, thinks it is red now, and not open. Sitting on a bedpan hurts due to the bed sore so the LTCF staff just let him/her go to the bathroom in the chair. Observation on 07/26/2022 at 1:10 PM, during the patient's LTCF visit, showed RN A failed to assess the patient's buttocks. During an interview on 07/26/2022 at 1:10 PM, RN A stated that: - The hospice aide (HHA) took a picture of the patient's buttocks that morning; - RN A told the HHA to ask the LTCF to have the wound nurse look at the wound; - No orders received as of this time; and - RN A stated, "Last week he/she asked the LTCF nurse for measurements and he/she didn't have any." During an interview on 07/26/2022 at 1:10 PM, the LTCF administrator stated that the patient had a stage three pressure ulcer and was healed on 06/08/2022. They have continued to use barrier cream on the patient's buttocks. Hospice lets the LTCF treat the wounds and they will evaluate the LTCF notes. "Until the patient's pain is controlled hospice drives the care". Hospice participates in the LTCF care plan meetings. During an interview on 07/27/2022 at 12:00 PM, RN A stated that he/she returned to the LTCF today and assessed the patient's buttocks. The patient had a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough [dead skin]) on the left buttocks, further up on the hip, and measured 0.2 centimeters (cm) by 0.2 cm. The findings were reviewed with the area clinical vice president and administrator, on 07/27/2022 at 2:55 PM. The clinical vice president agreed with the above findings and stated that he/she expected the plan of care to include individualized interventions. No additional information was provided by the survey exit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 06/10/2022 with a terminal diagnosis of chronic diastolic (congestive) heart failure (a syndrome in which the heart is unable to pump sufficient blood to meet the metabolic needs of the body), and secondary diagnoses of pulmonary embolism (blood clot in the lungs), history of falls, risk of aspiration, and dementia. The patient resided in his/her own home with care provided by his/her family members. Review of the documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 06/28/2022, 07/12/2022, and 07/26/2022 showed the report failed to contain specific interventions and goals for patient care including, but not limited to, management of right foot pain, management of constipation, and methods to reduce aspiration (inhaling of food/fluids during meals). During observation of the hospice interdisciplinary team meeting on 07/26/2022 at 11:58 AM, the IDG did not review the hospice Care Plan report for any of the patients when updating the hospice plan of care. During an interview on 07/27/2022 at 02:50 PM, the area clinical vice president stated that the Care Plan report shows the interventions and goals for the patient, and the Care Plan report is not reviewed during the interdisciplinary team meeting. RECORD/PATIENT #5: Review of the record showed the patient was admitted to hospice on 03/07/2022 with a terminal diagnosis of chronic obstructive pulmonary disease (difficulty breathing). Comorbidities included anxiety disorder, gastro-esophageal reflux disease, and nutritional deficiency. Review of the IDG comprehensive assessment and plan of care report, dated 05/31/2022, showed the RN documented the patient has lost 14 pounds since admission. Review of the RN subsequent visit note dated 05/20/2022, showed the patient had dysphagia (difficulty swallowing). Review of a RN coordination note dated 07/08/2022, showed the patient remains incontinent of bowel and wears pull-ups. He/she has fine tremors (involuntary movements/shaking) of upper extremities and sometimes cannot bring fork to mouth. The POC failed to show problems, goals and interventions for weight loss, dysphagia, tremors to upper extremities, and incontinence of bowels and supplies to be provided. The findings were reviewed with the area clinical vice president and administrator, on 07 /27/19 at 2:55 PM. No additional information was provided by the survey exit. During interviews the interim director of operations stated: - On 07/27/2022 at 11:34 AM, the Hospice IDG Comprehensive Assessment and Plan of Care Update report is what the agency uses for the updated plan of care; and - On 07/27/2022 at 12:45 PM, that the Hospice Plan of Care Report is not reviewed in the interdisciplinary group meetings.

Based on record review and interview, the agency failed to ensure the plan of care (POC) included the correct frequency of visits needed for the hospice aide in one (Record/Patient #3) of five records reviewed to meet the specific patient needs. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Hospice Plan of Care," dated 11/30/2021, showed, in part, the plan must include all services necessary for the palliation and management of terminal illness and related conditions, including but not limited to: scope and frequency of all services necessary to meet the needs of the patient. RECORD/PATIENT #3: Review of the plan of care dated 05/17/2022 through 08/14/2022, showed hospice aide (HHA) visits effective 05/17/2022, two times a week for one week (2 wk 1), and then four times a week for 12 weeks (4 wk 12). HHA service for assistance with personal care, hygiene, and activities of daily living (the patient resided in a long-term care facility - LTCF). Review of the HHA, care plan report, dated 05/17/2022 through 08/14/2022, showed assist staff/caregiver with Hoyer lift (mechanical lift used to transfer patient from one place to another) every visit. Other services included a secondary aide to assist every visit. Review of the HHA visit notes, dated 05/19/2022 through 07/16/2022, showed the following: - Week one (05/17/2022 through 05/21/2022) the HHA made one visit (physician order was for two visits week one); and - Week two through nine (05/22/2022 through 07/16/2022) the HHA saw the patient two times a week (the physician order was four times a week for 12 weeks). During an interview on 07/27/2022 at 2:50 PM, the rapid response case manager stated that the HHA visits 4 wk 13 meant two HHA visits a week by two HHA staff. There was no further information provided.

Based on agency policy, clinical record review, and interview the agency failed to assure that the the plan of care included all drugs and treatments necessary to meet the needs of the patient in three (Records/Patients #1, #2 and #3) of five full records reviewed. This deficient practice has the potential to affect the care planning for all the agency's patients. Findings included: Review of the agency's policy titled, "Hospice Plan of Care," dated 11/30/2021, showed, in part, the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms, and drugs and treatments necessary to meet the patients' needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/29/2022 with a terminal diagnosis of traumatic cerebral edema (swelling of the brain), and secondary diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), and nausea. The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, "Coordination Notes Report," dated 07/25/2022 showed that on 07/08/2022 and 07/11/2022 the agency provided Calazime paste (a barrier paste that contains calamine lotion) to the patient. Observation on 07/26/2022 at 12:52 PM, during the patient's home visit, the patient's spouse stated that the agency had provided him/her with Calazime paste to use in the event the patient gets redness on his/her buttocks. Review of the documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 07/12/2022 and 07/26/2022 showed that the documents failed to contain orders for the use of the Calazime paste for the patient. During an interview on 07/27/2022 at 11:30 AM, the area clinical vice president stated that they would have expected the plan of care to contain orders for the use of Calazime paste. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/18/2022 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a long term care facility (LTCF). Review of the document titled, "Coordination Notes Report," dated 07/25/2022 showed that on 06/09/2022 the agency provided Sensicare protective barrier (a cream/ointment used to protect the skin) to the patient. Review of the documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 07/12/2022 and 07/26/2022 showed that the documents failed to contain orders for the use of Sensicare protective barrier for the patient. During an interview on 07/27/2022 at 02:50 PM, the area clinical vice president stated that they would have expected the plan of care to contain orders for the use of Sensicare protective barrier for the patient. RECORD/PATIENT #3: Review of the RN start of care assessment dated 03/07/2022 showed the patient had a primary diagnosis of chronic obstructive pulmonary disease (COPD - difficulty breathing). Review of a social worker visit note dated 06/27/2022 showed the patient recently used Icy Hot patches (pain relief patch). Review of the physician orders showed no order for Icy Hot patches. Review of the IDG comprehensive assessment and POC update report dated 07/12/2021 showed no update of the POC or medication profile to include an order for Icy Hot patches. The findings were reviewed with the area clinical vice president and administrator on 07/27/19 at 2:55 PM. No additional information was provided by the survey exit.

Based on agency policy, clinical and facility record review, and interview the agency failed to ensure that the plan of care included all medical supplies and appliances necessary to meet the needs of the patient in two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect the care plans of all the agency's patients. Findings included: Review of the document titled, "Hospice Plan of Care," dated 02/22/2022 showed that the plan [of care] must include all services necessary for the palliation and management of the terminal illness and related conditions, including but not limited to, medical supplies and equipment necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/29/2022 with a terminal diagnosis of traumatic cerebral edema (swelling of the brain), and secondary diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), and nausea. The patient resided in his/her own home with the assistance of his/her spouse. Review of nursing visit documentation showed that: - On 06/29/2022 the patient ambulated with an assistive device; - On 06/30/2022 the nurse documented that he/she would order the patient a new walker; and - On 07/05/2022 the social worker documented that the patient used a walker and wheelchair. Review of the hospice plan of care and care plan updates showed that: - The document titled, "Hospice certification and Plan of Care," dated 06/29/2022 failed to list any assistive device for the patient; and - The documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 07/12/2022 and 07/26/2022 failed to list a wheelchair or walker as durable medical equipment (DME) used to assist the patient. During an interview on 07/27/2022 at 11:30 AM the area clinical vice president stated that the DME that the patient was using was not listed on the patient's hospice plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/18/2022 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a long term care facility (LTCF). Review of the facility document titled, "Order Summary Report," dated 07/26/2022 showed that the patient was to have a low air loss mattress on his/her bed beginning 03/22/2022, grab bars up on the bed to assist with bed mobility beginning 07/30/2021, and heel protectors on [both heels] when in bed beginning 04/01/2022. Review of the documents titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 06/14/2022, 06/28/2022, 07/12/2022, and 07/26/2022 failed to list the low air loss mattress, grab bars, and heel protectors as DME. During an interview on 07/27/2022 at 02:50 PM, the area clinical vice president stated that they expect that all DME used for the patient would be included in the plan of care.

Based on policy review, observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in one (Record/Patient #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "hand hygiene," dated 06/22/22 showed agency staff were to perform hand hygiene: - After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings; and - After removing gloves. Review of the agency's policy titled, "Bag Technique," dated 06/22/22 showed in part that staff: - Wash hands again if you need to re-enter the bag for additional supplies during patient care. Do not go back into the bag without removing gloves and performing hand hygiene; and - Hands are cleansed prior to returning clean equipment and supplies to the bag. RECORD/PATIENT #3: Observation on 07/26/2022, beginning at 12:30 PM, during the patient's home visit at a long term care facility (LTCF), showed registered nurse (RN) A performed a physical assessment for the patient. RN A touched the patient's scalp for wound evaluation. RN A failed to perform hand hygiene after physically touching the patient. RN A then proceeded to evaluate the patient's vital signs (blood pressure, pulse and oxygen saturation [measure of oxygen in the blood]). RN A failed to perform hand hygiene before placing vital sign equipment back in his/her bag. During an interview on 07/27/2022, beginning at 1:50 PM, the administrative staff concurred that they would expect the nurse to perform hand hygiene after patient contact and before contact with his/her supply bag.

Based on review of the written agreement for respite services, record review, and interview, the agency failed to obtain a discharge summary from the skilled nursing facility (SNF) that provided respite services for one (Record/Patient #8) of one patient record reviewed for respite care (inpatient care for caregiver relief). This deficient practice has the potential to affect coordination of care for hospice patients who receive respite care. Findings included: Review of the written agreement for respite services with the SNF that provided Patient #8's respite care, showed the facility must provide the hospice a copy of the clinical record including a discharge summary, at the time of discharge. RECORD/PATIENT #8: Record review showed the patient received respite care from 06/07/2022 to 06/11/2022. The record failed to include a discharge summary for the respite stay. During an interview on 07/27/2022, at 4:20 PM, the area vice president of operations stated that they did not have a discharge summary from the facility, until asked for by the surveyor.

Based on agency policy, clinical and facility record review, and interview, the agency failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care in two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect the coordination of care for all of the agency's patients who reside in a long term care facility (LTCF). Findings included: Review of the agency's policy titled, "Hospice Plan of Care," dated 02/22/2022 showed that when a patient resides in a nursing facility the hospice POC (Plan of Care) is established and maintained in consultation with the facility staff. All care provided must be in accordance with the hospice POC. The hospice POC shall: Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 02/18/2022 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a LTCF. Review of the document titled, "Coordination Notes Report," printed 07/25/2022 showed that on: - 07/14/2022 the patient was to use a low air loss mattress on his/her bed; - 07/10/2022 the agency provided underpads for the patient's bed and fit right wipes for personal care; - 06/09/2022 the agency provided Sensicare protective barrier ointment/cream; and - 06/06/2022 the agency provided adult briefs for the patient. Review of the facility document titled, "Order Summary Report," dated 07/26/2022 showed that the patient was to use: - A low air loss mattress on his/her bed; and - Heel protectors on when in bed. Review of the document titled, "Facility Care Coordination," dated 02/18/2022 failed to identify the care and services that were needed, and specifically identify which provider was responsible for: - Assistance with showers/bathing including, but not limited to, the day of the week hospice would provide care and the days the facility would provide care; - Which durable medical equipment and supplies would be provided by hospice, including but not limited to, the low air loss mattress, heel protectors, briefs, and barrier ointment/cream. During an interview on 07/27/2022 at 02:58 PM, area clinical vice president stated that they would expect the Facility Care Coordination plan to identify the specific interventions to be provided by the hospice and/or facility staff. RECORD/PATIENT #3 Review of the clinical record showed the patient was admitted to hospice services on 05/17/2022 with a terminal diagnosis of Parkinson's disease (chronic disorder of the nervous system characterized by tremors [shaking]). The patient resided in a LTCF. Review of the facility document titled, "Order Summary Report," dated 07/26/2022 showed that the patient was to use: - Mediseptic (skin protectant cream) three times a day for wound on buttock; - Cleanse wound at top of head with normal saline and apply triple antibiotic ointment and leave open to air at patient's request; - Obtain low loss air mattress and check placement every shift; and - This information was not on the hospice agency's plan of care. Review of the undated document titled, "Facility Care Coordination," failed to identify any care and services that were needed, and specifically identify which provider was responsible for was blank. During an interview on 07/26/2022 at 12:15 PM, registered nurse (RN A) stated that the coordination of care should not be blank and he/she should have filled it out. The coordination of care should be printed on the facility care coordination form. He/she communicated the information verbally. During an interview on 07/26/2022 at 1:40 PM, the facility licensed practical nurse stated that he/she hardly looks at the hospice book. The facility should incorporate the hospice plan of care into the LTCF plan of care.

Based on record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #3) of two applicable records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: RECORD/PATIENT #3: Review of the hospice record maintained at the LTCF, during a home visit observation on 07/26/2022 beginning at noon, showed it failed to contain the following required information: - Physician certification and recertification; and - Names, and days of the week visit information for hospice personnel involved in care of the patient. The findings were reviewed with the director of clinical services on 07/27/2022, at 11:00 AM. No further information was provided.

Based on policy review, record review, grievance file review, and interview, the agency failed to promote and protect the following patient rights: - To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of this deficient practice has the potential to affect all patients served by the agency.

Based on agency patient information booklet and policy, clinical record review, and interview, the agency failed to assure that patient's received effective symptom control (dyspnea and nausea) in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect the symptom management for all of the agency's patients. Findings included: Review of the agency's document titled, "Patient Information Booklet," dated 12/2021, showed that the section titled, "Patient Rights and Responsibilities," (on page 15) failed to contain verbiage stating that the patient had the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Review of the agency's policy titled, "Professional Management," dated 02/22/2022, showed that: - The hospice assumes responsibility for professional management of the patient's hospice services provided in accordance with the conditions of participation, and makes any arrangements necessary for hospice related inpatient care in a participating Medicare/Medicaid facility; - The hospice will designate an interdisciplinary team that will be responsible for: * Providing overall coordination of hospice care of the patient with the designated facility representative(s); * Communicating with the designated facility representative(s) and other health care providers participating in the provision of care for the terminal and related and other conditions to ensure quality of care for the patient/family; and - Information furnished to the facility includes, but is not limited to, the patient's pain and symptom management needs. Review of the agency's policy titled, "Medication Management," dated 04/28/2022 showed that: - It is the responsibility of the nurse to obtain a pain/symptom history from the patient/caregiver. The nurse will then compare the amount of the drug remaining to the amount of medication usage determined by the pain or symptom history and document that a medication review was performed on the hospice nurse visit note; and - Medication reconciliation will be done at admission, recertification, a change in patient's condition requiring medication changes, when a medication is a new order. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 05/20/2022 with a terminal diagnosis of chronic obstructive pulmonary disease (a condition that causes obstructed air flow from the lungs). The patient resided in a skilled nursing facility. Review of the registered nurse (RN) start of care visit documentation dated 05/20/2022 showed that the patient: - Had abnormal breath sounds (crackling), dyspnea (difficulty breathing), and required oxygen per nasal cannula (a tube going into the nose). The patient rated his/her dyspnea a 4 on a 0-10 high scale, and was using albuterol (a medication to relax the airways) and Symbicort (a medication to reduce inflammation in the lungs) to treat the dyspnea; and - Had a nausea score of 2 on a 0-10 high scale, with nausea not significantly affecting the patient. Review of the document titled, "Hospice Certification and Plan of Care," dated 05/20/2022 showed that: - Hospice nurse to assess effectiveness of cardiopulmonary symptom relief measure including oxygen treatment and comfort modalities; and - Hospice nurse to coordinate plan of care with facility staff. Review of RN subsequent visit dated 05/21/2022 showed that the patient: - Had rhonchi (low pitched wheezed/coarse crackling in the lungs), was dependent on nebulizers and oxygen via nasal cannula, and rated his/her dyspnea at a 4 during the visit and a five at the worse in the past 24 hours; - Had nausea rated at a three, with nausea significantly affecting the patient, the patient reported nausea a 5 at the worst level in the last 24 hours, and the patient was using ondansetron (a medication for nausea); and - The RN reviewed the hospice plan of care with facility staff during the visit. Review of the facility medication administration record showed that: - The patient failed to receive the following medications on 05/21/2022: * Montelukast Sodium (a medication used to treat dyspnea); * Fluticasone-Salmeterol Aerosol (a medication used to treat dyspnea; * Symbicort; * Albuterol nebulizers at 08:00 AM, 12:00 PM, and 06:00 PM; - The patient failed to receive the following medications on 05/22/2022: * Fluticasone-Salmeterol Aerosol (a medication used to treat dyspnea); and - The facility staff did not administer any doses of ondansetron for nausea. During an interview on 05/26/2022 at 03:15 PM, RN1 stated that: - He/she did not check the facility medication administration record to assure that the patient had received his/her medications; and - He/she, "typically expect the facility to do the medications." The nurse documented the patient was having symptoms of nausea and dyspnea, and that the symptoms were managed using odanestron, albuterol, and Symbicort. The hospice nurse documented the facility staff was administering the medications, when the facility medication administration record failed to contain documentation that the medications were administered.